Skip to main content

Is Pre-season Eccentric Strength Testing During the Nordic Hamstring Exercise Associated with Future Hamstring Strain Injury? A Systematic Review and Meta-analysis

A Correction to this article was published on 08 May 2021

This article has been updated



Interventions utilising the Nordic hamstring exercise (NHE) have resulted in reductions in the incidence of hamstring strain injury (HSI). Subsequently, quantifying eccentric knee flexor strength during performance of the NHE to identify an association with the occurrence of future HSI has become increasingly common; however, the data to date are equivocal.


To systematically review the association between pre-season eccentric knee flexor strength quantified during performance of the NHE and the occurrence of future HSI.


Systematic review and meta-analysis.

Data sources

CINAHL, Cochrane Library, Medline Complete, Embase, Web of Science and SPORTDiscus databases were searched from January 2013 to January 10, 2020.

Eligibility criteria for selecting studies

Prospective cohort studies which assessed the association between pre-season eccentric knee flexor strength quantified during performance of the NHE and the occurrence of future HSI.


Following database search, article retrieval and title and abstract screening, articles were assessed for eligibility against pre-defined criteria then assessed for risk of bias. Meta-analysis was used to pool data across studies, with meta-regression utilised where possible.


A total of six articles were included in the meta-analysis, encompassing 1100 participants. Comparison of eccentric knee flexor strength during performance of the NHE in 156 injured participants and the 944 uninjured participants revealed no significant differences, regardless of whether strength was expressed as absolute (N), relative to body mass (N kg−1) or between-limb asymmetry (%). Meta-regression analysis revealed that the observed effect sizes were generally not moderated by age, mass, height, strength, or sport played.


Eccentric knee flexor strength quantified during performance of the NHE during pre-season provides limited information about the occurrence of a future HSI.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Change history


  1. Ekstrand J, Walden M, Hagglund M. Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. Br J Sports Med. 2016;50(12):731–7.

    PubMed  Article  Google Scholar 

  2. Orchard JW, Seward H, Orchard JJ. Results of 2 decades of injury surveillance and public release of data in the Australian Football League. Am J Sports Med. 2013;41(4):734–41.

    PubMed  Article  Google Scholar 

  3. Roe M, Murphy JC, Gissane C, et al. Time to get our four priorities right: an 8-year prospective investigation of 1326 player-seasons to identify the frequency, nature, and burden of time-loss injuries in elite Gaelic football. PeerJ. 2018;6:e4895.

    PubMed  PubMed Central  Article  Google Scholar 

  4. Hallén A, Ekstrand J. Return to play following muscle injuries in professional footballers. J Sports Sci. 2014;32(13):1229–36.

    PubMed  Article  Google Scholar 

  5. Ruddy JD, Pietsch S, Maniar N, et al. Session availability as a result of prior injury impacts the risk of subsequent non-contact lower limb injury in elite male Australian footballers. Front Physiol. 2019;10:737.

    PubMed  PubMed Central  Article  Google Scholar 

  6. Hoffman DT, Dwyer DB, Bowe SJ, et al. Is injury associated with team performance in elite Australian football? 20 years of player injury and team performance data that include measures of individual player value. Br J Sports Med. 2020;54(8):475–9.

    PubMed  Article  Google Scholar 

  7. Verrall GM, Kalairajah Y, Slavotinek JP, et al. Assessment of player performance following return to sport after hamstring muscle strain injury. J Sci Med Sport. 2006;9(1–2):87–90.

    CAS  PubMed  Article  Google Scholar 

  8. Whiteley R, Massey A, Gabbett T, et al. Match high-speed running distances are often suppressed after return from hamstring strain injury in professional footballers. Sports Health. 2020. ([Online ahead of print]).

    Article  PubMed  PubMed Central  Google Scholar 

  9. van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med. 1992;14(2):82–99.

    PubMed  Article  Google Scholar 

  10. Finch C. A new framework for research leading to sports injury prevention. J Sci Med Sport. 2006;9(1–2):3–9.

    PubMed  Article  Google Scholar 

  11. Green B, Bourne MN, van Dyk N, et al. Recalibrating the risk of hamstring strain injury (HSI)—a 2020 systematic review and meta-analysis of risk factors for index and recurrent HSI in sport. Br J Sports Med. 2020;2020:4.

    Google Scholar 

  12. Bahr R, Holme I. Risk factors for sports injuries–a methodological approach. Br J Sports Med. 2003;37(5):384–92.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  13. van Dyk N, Behan FP, Whiteley R. Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes. Br J Sports Med. 2019;53(21):1362–70.

    PubMed  Article  Google Scholar 

  14. Al Attar WSA, Soomro N, Sinclair PJ, et al. Effect of injury prevention programs that include the nordic hamstring exercise on hamstring injury rates in soccer players: a systematic review and meta-analysis. Sports Med. 2017;47(5):907–16.

    PubMed  Article  Google Scholar 

  15. Opar DA, Piatkowski T, Williams MD, et al. A novel device using the Nordic hamstring exercise to assess eccentric knee flexor strength: a reliability and retrospective injury study. J Orthop Sports Phys Ther. 2013;43(9):636–40.

    PubMed  Article  Google Scholar 

  16. Opar DA, Williams MD, Timmins RG, et al. Eccentric hamstring strength and hamstring injury risk in Australian footballers. Med Sci Sports Exerc. 2015;47(4):857–65.

    PubMed  Article  Google Scholar 

  17. Timmins RG, Bourne MN, Shield AJ, et al. Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. Br J Sports Med. 2016;50(24):1524–35.

    PubMed  Article  Google Scholar 

  18. van Dyk N, Bahr R, Burnett AF, et al. A comprehensive strength testing protocol offers no clinical value in predicting risk of hamstring injury: a prospective cohort study of 413 professional football players. Br J Sports Med. 2017;51(23):1695–702.

    PubMed  Article  Google Scholar 

  19. Bourne MN, Opar DA, Williams MD, et al. Eccentric knee flexor strength and risk of hamstring injuries in rugby union: a prospective study. Am J Sports Med. 2015;43(11):2663–70.

    PubMed  Article  Google Scholar 

  20. Ruddy JD, Shield AJ, Maniar N, et al. Predictive modeling of hamstring strain injuries in elite Australian footballers. Med Sci Sports Exerc. 2018;50(5):906–14.

    PubMed  Article  Google Scholar 

  21. Roe M, Delahunt E, McHugh M, et al. Association between eccentric knee flexor strength and hamstring injury risk in 185 elite Gaelic football players. Scand J Med Sci Sports. 2020;30(3):515–22.

    PubMed  Article  Google Scholar 

  22. Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210.

    PubMed  PubMed Central  Article  Google Scholar 

  23. Hayden JA, van der Windt DA, Cartwright JL, et al. Assessing bias in studies of prognostic factors. Ann Intern Med. 2013;158(4):280–6.

    PubMed  Article  Google Scholar 

  24. Balduzzi S, Rücker G, Schwarzer G. How to perform a meta-analysis with R: a practical tutorial. Evid Based Ment Health. 2019;22(4):153–60.

    PubMed  Article  Google Scholar 

  25. Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat Softw. 2010;36(3):48.

    Article  Google Scholar 

  26. R Development Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2020.

  27. Cohen J. Statistical power analysis for the behavioral sciences: Lawrence Erlbaum; 1988.

  28. Petersen J, Thorborg K, Nielsen MB, et al. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomized controlled trial. Am J Sports Med. 2011;39(11):2296–303.

    PubMed  Article  Google Scholar 

  29. van der Horst N, Smits DW, Petersen J, et al. The preventive effect of the nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial. Am J Sports Med. 2015;43(6):1316–23.

    PubMed  Article  Google Scholar 

  30. Timmins RG, Ruddy JD, Presland J, et al. Architectural changes of the biceps femoris after concentric or eccentric training. Med Sci Sports Exerc. 2016;48(3):499–508.

    PubMed  Article  Google Scholar 

  31. Presland JD, Timmins RG, Bourne MN, et al. The effect of Nordic hamstring exercise training volume on biceps femoris long head architectural adaptation. Scand J Med Sci Sports. 2018;28(7):1775–83.

    CAS  PubMed  Article  Google Scholar 

  32. Pollard CW, Opar DA, Williams MD, et al. Razor hamstring curl and Nordic hamstring exercise architectural adaptations: Impact of exercise selection and intensity. Scand J Med Sci Sports. 2019;29(5):706–15.

    PubMed  Article  Google Scholar 

  33. Bourne MN, Duhig SJ, Timmins RG, et al. Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: implications for injury prevention. Br J Sports Med. 2017;51(5):469–77.

    PubMed  Article  Google Scholar 

  34. Lacome M, Avrillon S, Cholley Y, et al. Hamstring eccentric strengthening program: does training volume matter? Int J Sports Physiol Perform. 2019;2019:1–27.

    Google Scholar 

  35. Alonso-Fernandez D, Docampo-Blanco P, Martinez-Fernandez J. Changes in muscle architecture of biceps femoris induced by eccentric strength training with nordic hamstring exercise. Scand J Med Sci Sports. 2018;28(1):88–94.

    CAS  PubMed  Article  Google Scholar 

  36. Ribeiro-Alvares JB, Marques VB, Vaz MA, et al. Four weeks of Nordic hamstring exercise reduce muscle injury risk factors in young adults. J Strength Cond Res. 2018;32(5):1254–62.

    PubMed  Article  Google Scholar 

  37. Timmins RG, Bourne MN, Hickey JT, et al. Effect of prior injury on changes to biceps femoris architecture across an Australian Football League season. Med Sci Sports Exerc. 2017;49(10):2102–9.

    PubMed  Article  Google Scholar 

  38. Ruddy JD, Pollard CW, Timmins RG, et al. Running exposure is associated with the risk of hamstring strain injury in elite Australian footballers. Br J Sports Med. 2018;52(14):919–28.

    PubMed  Article  Google Scholar 

  39. Duhig S, Shield AJ, Opar D, et al. Effect of high-speed running on hamstring strain injury risk. Br J Sports Med. 2016;50(24):1536–40.

    PubMed  Article  Google Scholar 

  40. Buchheit M, Cholley Y, Nagel M, et al. The effect of body mass on eccentric knee-flexor strength assessed with an instrumented Nordic hamstring device (NordBord) in football players. Int J Sports Physiol Perform. 2016;11(6):721–6.

    PubMed  Article  Google Scholar 

  41. Greenland S, Mansournia MA, Altman DG. Sparse data bias: a problem hiding in plain sight. BMJ. 2016;352:i1981.

    PubMed  Article  Google Scholar 

  42. Lin L. Bias caused by sampling error in meta-analysis with small sample sizes. PLoS ONE. 2018;13(9):e0204056.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  43. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane handbook for systematic reviews of interventions version 6.0 (updated July 2019). Cochrane; 2019.

  44. Hickey JT, Hickey PF, Maniar N, et al. A novel apparatus to measure knee flexor strength during various hamstring exercises: a reliability and retrospective injury study. J Orthop Sports Phys Ther. 2018;48(2):72–80.

    PubMed  Article  Google Scholar 

  45. Hegyi A, Lahti J, Giacomo JP, et al. Impact of hip flexion angle on unilateral and bilateral nordic hamstring exercise torque and high-density electromyography activity. J Orthop Sports Phys Ther. 2019;49(8):584–92.

    PubMed  Article  Google Scholar 

  46. IntHout J, Ioannidis JP, Rovers MM, et al. Plea for routinely presenting prediction intervals in meta-analysis. BMJ Open. 2016;6(7):e010247.

    PubMed  PubMed Central  Article  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to David A. Opar.

Ethics declarations


No sources of funding were used to assist in the preparation of this article.

Conflict of interest

Dr David Opar is listed as a co-inventor on a patent filed for a field-testing device of eccentric hamstring strength (PCT/AU2012/001041.2012) and is a minority shareholder in Vald Performance Pty Ltd, the company responsible for commercialising the device. The association between measures derived from the device and future hamstring strain injury is directly examined in this manuscript. Dr Opar is also the Chair of the Vald Performance Research Committee, a role that is unpaid. Dr Opar has received funding from Vald Performance for research unrelated to the current manuscript. Dr Opar’s brother and brother-in-law are employees of Vald Performance. Dr Opar’s brother is a minority shareholder in Vald Performance Pty Ltd. Ryan Timmins, Fearghal Behan, Jack Hickey, Nicol van Dyk, Kara Price and Nirav Maniar declare that they have no conflicts of interest relevant to the content of this review.

Availability of data and material

Access to data and/or material can be sought via contacting the corresponding author.

Code availability

Not applicable.

Authorship contributions

DAO, RGT, FPB, JTH, NM conceived the study. DAO, FPB and KP completed study protocol and registration. DAO and RGT completed database searches and extraction. RGT and JTH completed title and abstract screening. FPB and JTH completed full text review. RGT, NvD and FPB completed risk of bias assessment. NM, JTH and NvD completed data extraction. NM and JTH completed data analysis. DAO drafted the Introduction and Methods. NM drafted the Results and Discussion. All authors reviewed, revised and approved the final manuscript.

Additional information

The original artilce has been updated: Due to authors middle name udpate.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 715 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Opar, D.A., Timmins, R.G., Behan, F.P. et al. Is Pre-season Eccentric Strength Testing During the Nordic Hamstring Exercise Associated with Future Hamstring Strain Injury? A Systematic Review and Meta-analysis. Sports Med 51, 1935–1945 (2021).

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: